Forms

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A

ADA (Americans with Disabilities Act)

Essential and Marginal Job Functions Worksheet
Reasonable Accommodation Request and Documentation Form

Affidavit of Eligible Spouse/Child Status

Application for IU Employment (Service Maintenance and Hourly)
see Employment Application

Approval Form for a Leave for Development of Commercial Projects with a Non-University Entity

Authorization Form for Motor Vehicle Records Check (Office of Insurance, Loss Control & Claims)

B

Background Check Consent Form

Beneficiary designation

Basic Life Insurance
Personal Accident Insurance
Supplemental Group Life Insurance

C

Claim forms

Dental expenses (CIGNA)

IU Health Center Claim Form (student health insurance only)

Medical expenses for all plans

Prescription Drug Claim Form for all plans

TSB Healthcare and Dependent Care Claim form

Classification Appeal Form

Commercial Leaves form (see Approval Form for a Leave …)

D

Dental Claim Form (CIGNA)

Dependent Care Flexible Spending Account Worksheet (TSB)

Dependent child

Application/Affidavit to Establish Dependency by Guardianship

Certification of Disabled Dependent Child Eligibility

Domestic partnership

Affidavit of Domestic Partnership

Certification of Tax-Qualified Dependents

Same-Sex Domestic-Partner Health Plan Benefit Tax Estimation Work Sheet
   - 2012
   - 2013

Termination of Domestic Partnership

Termination of Tax-Qualified Dependent Status

Drug Testing

Statement of Facts Supporting Reasonable Cause of Drug or Alcohol Use by Employee

Employee Authorization and Consent to Submit to Substance Abuse Testing

Employee Refusal to Submit To Substance Abuse Testing

Highlights of a Conditional Employment Agreement

Request for Alcohol/Drug Screening (campus-specific form and procedures at Office of Insurance, Loss Control & Claims site)

 

E

Employee Recognition Award Plan

Employee Written Authorization for Release of Personnel File(s)

Employment Application (Service Maintenance and Hourly)

Application | | RTF
Background Check Consent Statement
Work History Supplement

Essential and Marginal Job Functions Worksheet

F

Family Status Change

Fee Courtesy (see Tuition Benefit)

 

FMLA (Family and Medical Leave Act)

Certification of Qualifying Exigency for Military Family Leave

Certification for Serious Injury or Illness of Covered Service Member

FMLA Definition of Serious Health Conditions

FMLA Form 1 Leave Notice of Designation, Request, & Approval

Essential and Marginal Job Functions Worksheet

FMLA Form 2E Medical Certification for EMPLOYEE

FMLA Form 2F Medical Certification for FAMILY

FMLA Form 3 Intent to Return and Fitness for Duty/Medical Release

Medical Recertification Request

Tracking Sheet

Form I-9 and Instructions

G

Grievance forms

Hourly Employees

Professional and Non-union Support and Service Staff

Bloomington:
Service Maintenance Employees
Support Staff

H

Health Savings Contribution Change Form

Hourly positions employment application (see Employment Application)

I

I-9 Form and Instructions

Incentive Pay or Commission Plan

IU Tuition Benefit (see Tuition Benefit, IU)

J

K

L

Leaves for Military Families Request Form |

Long-term Disability Insurance

Claim Packet

Enrollment form |

Medical History Statement for Non-Indiana Residents

Medical History Statement for Residents of Indiana

M

Mass Transit Expense Claim form

Medco Rx forms (see Prescription Drug forms)

Medical claim forms (see Claim forms)

Medical History Statement for Indiana Residents

Medical History Statement for Non-Indiana Residents

Motor Vehicle Records Check -- Authorization Form (Office of Insurance, Loss Control & Claims)

N

O

P

PERF Change of Address

PERF Change of Beneficiary

PERF Change of Name

Personal Accident Insurance (PAI)

Beneficiary Designation

Enrollment form

Personal Profile Forms

Change Form, Personal Data

Personal Profile Form (ED)

Personal Profile Form (PS)

Personal Profile Form (PSA)

Personnel File(s), Employee Written Authorization for Release

Position Description Form

Prescription Drug Claim Form

Prescription Drug Mail Order Form

Prescription Drug Refill Request Form

Q

R

Reasonable Accommodation Request and Documentation Form

S

Separating Employment from IU

Employee Checklist

Supervisor Checklist

Service Maintenance positions employment application (see Employment Application)

Bloomington:
Staff Report (For long documents)

Staff Report (For short documents; requires Adobe Reader 7.0.)

Bloomington:
Staff Position Posting Request Form (goes to University OLA staff side)

Student health insurance

IU Health Center Claim Form

See the Student Health Insurance web pages for forms specific to each plan

Supplemental Life Insurance

Beneficiary Designation

Enrollment Form |

Medical History Statement for Non-Indiana Residents

Medical History Statement for Residents of Indiana

T

Tax Saver Benefit (TSB) Plan

TSB Healthcare and Dependent Care Claim form

Dependent Care Flexible Spending Account Worksheet (TSB)

Direct Deposit Authorization/Termination form (TSB)

* See the Benefits Change Connection about making changes to your plan

Bloomington:
Telephone Reference Check

Tuition Benefit (formerly Fee Courtesy)

2012-2013 IU Tuition Benefit Enrollment Form |

2011-2012 IU Tuition Benefit Enrollment Form

IUHS Tuition Waiver Form |

U

Service Maintenance positions Bloomington:
Unsafe Working Conditions |

V

W

Service Maintenance positions Bloomington:
Work History Supplement (see Employment Application)

X

Y

Z

 

 

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